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Enhancing Patient Care with Physician-Driven
Documentation
Session #46, February 12, 2019
Vinay Vaidya, MD, VP & CMIO,
Michael Shishov, MD, MPH, Chief Pediatric Rheumatology
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Vinay Vaidya, MD & Michael Shishov, MD, MPH
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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• Ambulatory EMR Clinical Documentation Strategy
• Documentation usage & efficiency outcomes
• Improvements in clinical documentation
• Real-time dashboards from structured data
• Dashboards supporting chronic disease management
• Lessons Learned
Agenda
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1. Develop a clinical IT plan that places patients first and includes a
well-planned vision for end goals
2. Apply input from clinical end-users to ensure wide-spread
adoption
3. Perform systematic updates based on user feedback and to
address evolving needs
4. Design workflows that capture critical data without compromising
productivity
5. Identify in advance what data to capture to drive better patient
outcomes
Learning Objectives
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Phoenix Children’s Hospital
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• 30 Years Old
• 433 Licensed Beds
• 6
th
largest children’s
• 16,000 Surgical cases
• 18,000 annual admissions
• 80,000 ED admissions
• 237,000 Outpatient visits
• 75+ Subspecialties
Phoenix Children’s Hospital
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EMR/Clinical Documentation Journey
• Allscripts EMR platform: Inpatient and ED more than 15 years
• Ambulatory: paper-based until 2014
• 35 + Ambulatory Pediatric Subspecialties
• Search for advanced clinical documentation solutions for
Ambulatory EMR that would meet our KEY REQUIREMENTS
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Clinical Documentation: Key
Requirements
• Easy and rapid build for disease specific templates
• Ease of use for providers
• Easy to extract and harness structured data for enhancing
quality
• Easy to update and maintain
• END GOAL: Clinical documentation would drive
improvements in Chronic Disease Management
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Ambulatory Clinical Documentation:
Challenges in Capturing Structured Data
Is this what ease of use looks like?
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Clean, modern web-based interface
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rd
Party Documentation Solution
Underlying > 250K coded terms
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.. From Blank Template
Blank Template
Step 1
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.. To Templates That Build
Themselves (almost!)
Step 2
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Asthma Template: Start
Using
Step 3
Positive finding
Negative finding
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• 4 to 6 sessions per specialty over 6 -8 weeks
• 80+ Templates > 35 + Divisions
• 3 to 5 clinics at a time, rolling Ambulatory Go-Live over 2.5
years
• Ability to batch modify/update
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Template Build & Update
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… Many Complex Templates
Allergy Testing…
..Complex Bone Marrow
Transplant
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Documentation Solution
EMR (Remotely hosted)
Documentation
Local Data warehouse
+
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Successful EMR Integration
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> 1.6 million documents since 2014
Avg ~ 70,000 documents/month
70K
Successful User Adoption
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Key Documentation in Juvenile Arthritis
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Disease Activity Metrics in Juvenile
Arthritis (CID & cJADAS)
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OUTCOMES
Improved Clinical
Documentation
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Improved Documentation of 5 Key
Quality Measures
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Documentation of Disease
Activity in > 95%
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Outcomes: Physician
Productivity
Better Documentation
Without Increased EMR
completion times
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3 Metrics to Measure Documentation
Burden
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After hours
Weekends
Hours to
Hours to finalize
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Time to Document Completion
Rheumatology Division
98%
complete in
< 24 hour
87% complete
by 5pm on
DOS
100%
completed on
Weekdays
Total # Documents
Median Hrs
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Improved & efficient documentation =
Near elimination of all transcription
~ $1 million annual saving
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Real-time actionable dashboards: The
key to chronic disease management
• Well designed templates, disease specific
content
• Easy to use and document key quality metrics
• Valuable structured data flowing to the data
warehouse
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From Traditional SSRS reports to rich,
interactive visualization
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..from entire
population view
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..to a single
patient view
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..to a patient friendly view
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..to tracking disease complications
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..to provider metrics
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Summary
EMR
Documentation
Data warehouse
Dashboards
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Dashboards
Docum.
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• Data warehouse Analysis Services Data Cubes
– General Tables: eg Visits, Orders, Results, Documents
– Disease Specific Tables: JIA, Diabetes, Sickle Cell etc
• Microsoft Power BI Desktop Software for Visualization
• Microsoft on premises Report Server for publishing reports
• Security: Role level access
• Resources: Data analyst, Clinical Analyst, CMIO, Clinical user
• Time frame:
– Draft version: 1 to 2 weeks
– “Final” version: 2 to 3 months
– “Enhancements”: NEVER end!
Dashboard Development Details
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Clinical outcomes: Averaged >60%
Inactive Disease at last visit
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Challenges / Barriers
• Complex clinical requirements
• Limited IT resources
• Gaining physician buy-in
• Adoption of new processes
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Recommendations / Lessons Learned
• TOP PRIORITY: Patient first!
• TARGET: End goal in mind
• TOOLKIT: Strategic selection of tools: Documentation
solution, Data warehouse, Dashboard
• TEAMWORK: Strong, ongoing, reiterative clinician and IT
collaboration
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What’s Next? Chronic Disease Mg.
Type I Diabetes
Sickle Cell
Asthma
Cystic Fibrosis Inflammatory Bowel Disease
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What’s Next: Integration with EMR
